How Good is Your Stroke Scale?

2. How Good is Your Stroke Scale? Sean Kivlehan, MD, MPH, NREMT-P September 2013

4. Outline • Stroke Review • Treatment review • Rehab  tPA  recognition & time matters • Scale development and flaws • Systems issues • Future directions

5. Case #1 62 year old male, low speed MVC into pole, conscious with flaccid left arm, facial droop, and slurred speech. BP 220/100

6. Case #2 89 year old female, daughter called because she has been vomiting for past 2 hours, is dizzy, and can’t stand. No facial droop, normal speech, no focal weakness. BP 220/100. Actively vomiting.

7. Case #3 70 year old female found down in her apartment when son went to check on her. Last seen normal at dinner last night. Now semi-conscious but following commands, not moving right side. BP 200/90.

8. We’ve come far but still have a long way… HISTORY

9. “Apoplexy” • What they called it from Hippocrates on… • 1950’s: TIA’s • 25 years ago: Imaging • 10 years ago: Imaging in community hospitals • 1970 WHO definition: “rapidly developing clinical signs of focal (or global) disturbance of cerebral function, lasting more than 24 hours or leading to death, with no apparent cause other than that of vascular origin.” Sacco 2013

10. TIA’s 1975: “episodes of temporary and focal dysfunction of vascular origin, which are variable in duration, commonly lasting from 2 to 15 minutes, but occasionally lasting as long as a day (24 hours). They leave no persistent neurological deficit.” 2002: “A TIA is a brief episode of neurologic dysfunction caused by focal brain or retinal ischemia, with clinical symptoms typically lasting less than one hour, and without evidence of acute infarction.”

11. Unclear 2009: “a transient episode of neurological dysfunction caused by focal brain, spinal cord, or retinal ischemia without acute infarction.”

12. What is a Stroke Today? • Ischemic Stroke (clot: thomboticvs embolic) – 87% 2. Hemorrhagic Stroke (bleed: intracerebralvs subarachnoid; aneurysms & AVM’s) – 13% 3. Transient Ischemic Attack (TIA) Caused by clot, last <5 min, no permanent injury

13. A long way to go • Number 4 cause of death in US (down from #3 in 2008) • 785,000 in US a year • Less than half of 911 calls made within 1 hour of onset • Newest AHA/ASA outreach: FAST • 1 of 3 in 88% of strokes • Recalled well in 3 months (public) • Only 53% of strokes arrive by EMS in US

14. Jauch 2013

15. Vessels & Risk ANATOMY OF A STROKE

21. Where is the Stroke? • Anterior Circulation • Weakness • Aphasia • Sensory deficit • Posterior Circulation • Dizzy • Vomiting • Ataxia

22. Now that we have the vessels down, how do they get messed up?

23. Source: Arizona.edu

24. Ischemic

25. Hemorrhagic 40% mortality @ 30 days! Sacco 2013

29. What Causes These Things? Embolic • Bacterial emboli from valvularvegetations • Blood clots from cardiac dysrhythmias • Platelet-fibrin complex from atherosclerotic plaque disruption • Septic emboli from infection • Fat emboli from traumatic injury • Particulate emboli from IV drug injection Thrombotic • Secondary to intrinsic vascular disease in the occluded vessel • Atherosclerotic disease most common cause in U.S. • Other causes include • Vasculitis • Hypercoagulable states • Polycythemia • Vascular dissection

30. Risk • CAD: Double • HTN: Triple • Cardiac Failure: Quadruple • A-Fib: Quintuple Wolf, Stroke, 1991

32. And what about those TIA’s? • 4 to 20% will progress to stroke within 90 days • Half of those in first 24 hours • ABCD2 score • Age (>60) • Blood Pressure (>140/90) • Clinical Features (weakness/speech) • Duration (>60 minutes) • Diabetes Koenig, NEJM, 2007

33. From Rehab to Cure TREATMENT

34. Treatment Old teaching – 5 pages out of 1100 Focused on recognition, managing airway, manage herniation symptoms

35. Suddenly, a cure!

36. What we KNOW • Earlier recognition  Earlier EMS • Earlier EMS  Earlier ED notification • Earlier ED notification  Earlier imaging • Earlier imaging  Earlier tPa • Earlier tPa  Better outcomes

37. AHA Implementation Strategy for EMS within Stoke Systems of Care (1997)

38. Key Things • Check a sugar • And the pupils! • Prior stroke/seizures? • Time of onset! • Wake up strokes • Stroke mimickers

40. EMS Interventions • ABC’s etc • Oxygen to maintain SpO2 >94% • Head of bed flat for SBP <120 and give isotonic saline • Antihypertensive treatment controversial (>220) • Glucose if FS <60 • Establish PIV • Labs if build into system • None of this should delay transport Jauch 2013

41. The most important piece of info…. • Time patient last seen normal • EMS often the only people that can get this info on scene (family, bystanders) • Also: • Signs of hx of seizures or trauma on scene • PMHx (prior stroke, diabetes, HTN, AF • Meds on scene (anticoagulants) • Recent illness, surgery, trauma • Collect phone numbers, code status, family members • Bring family to ED EMS are the eyes & ears of the ED

42. tPA (Fibrinolytic Therapy) • FDA approved in 1996 for 3 hour window • Showed symptom improvement at 24 hours and 1 year (OR 1.9; CI 1.2-2.9) • ICH: 6.4% in tPA and 0.6% in placebo • 3 to 4.5 hour window w/ extra exclusions • 4.5 to 6 hour window did not help NINDS, NEJM, 1995

43. Jauch 2013

44. Mechanical Retrieval & IA tPA • Merci • Penumbra • Solitaire • Trevo • IA tPA ok for up to 6 hours • Good for patients with IV tPA contraindications • Can give in addition to IV tPA